TN 15 (12-98)

A. Introduction

Payees need certain identifying and financial information for reference as they read the instructions and complete the questions on the Representative Payee Report of Benefits and Dedicated Account, SSA-6233-BK. This section covers the information which should be provided on the report based on your review of the SSR. It also provides instructions for handling cases selected for monitoring but, based on your review, you determine that the past-due benefits did not meet the criteria for a dedicated account. (See GN 00605.215B.3. IMPORTANT below)

B. Procedure

1. Identifying Information

Fill in the following:

• Payee Name and Address; and

• Beneficiary Social Security Number; and

• Report Period (FROM: and TO: dates); and

• Beneficiary Name

2. Question 3 - Use of Benefits Information

Fill in the following:

• Benefits paid during the report period; and

• Benefits reported as saved from prior years; and

• Total Accountable Benefits Amount

NOTE: Determine the benefits paid during the report period from the PMTH segment of the SSR, and the benefits saved from the conserved funds (CF:) field in the REPY segment. Benefits paid should not include any past-due SSI benefits SSA deposited into the dedicated account. If the case is concurrent, query the Payment History Update System (PHUS) to determine the title II benefits paid during the report period.

3. Question 6 - Dedicated Account Information

Fill in the following:

• Past-due SSI benefits SSA deposited in Dedicated Account during the report period; and

• Balance in Dedicated Account as reported on a prior report; and

• Total Dedicated Account Amount

NOTE: Determine the past-due benefits SSA deposited into the dedicated account during the report period by reviewing the PMTH segment of the SSR for an “X, 1, 2, or F” in pay flag 5. Determine the balance in the account by reviewing the dedicated account balance field in the DACT segment (See GN 00605.205B.1.).

IMPORTANT: When the system determines a dedicated account based on the payment amount (PMTH), it is assumed that FO personnel paid the past-due benefits into a dedicated account but failed to establish the indicator(s) “'X, 1, 2, or F” in pay flag 5. Some overselection of potential dedicated account cases may occur since the systems selection process did not consider individual State supplement payments in computing the amount required to establish a dedicated account (due to the large variance in State supplement amounts). Therefore, dedicated accounts were never actually established for these overselected cases. When computing the dedicated account information, if you determine that the past-due benefits meet the dedicated account criteria, include this amount under “SSA Deposited in Dedicated Account” for question 6 above. If you determine that the past-due benefits did not meet the criteria for a dedicated account, obtain an annual accounting SSA-623, and update the SSR following the instructions in GN 00605.230B.1., DI Diary Set-No Dedicated Account Exists.

4. Mail For Completion

Mail the SSA-6233-BK to the payee for completion. The report can also be completed through telephone contact and mailed to the payee for signature, or in a face-to-face interview, if FO resources permit.

5. Retain Completed Reports

Completed SSA-6233-BKs must be retrievable in the event of a report is needed in a misapplication, misuse, or fraud investigation. The field office should fax the completed SSA-6233-BK into the Non Disability Repository (NDRED) (GN 00301.310). Once the report has been faxed into the NDRED, the paper SSA-6233 need not be retained (GN 00301.322).

REMINDER: Do not send the completed SSA-6233-BK to the Program Centers or the Wilkes-Barre Direct Operations Center for storage.

C. Reference

• How to Determine the Report Period, GN 00605.020B.2.

• How to Interpret Pay Flag 5, SM 01601.835